Diabetes Has Gotten Pretty Darn Complicated

i n the United States, 8% of our population has been diagnosed with diabetes, and 4% has diabetes that remains undiagnosed. Current projections suggest that the prevalence of diabetes will increase to 20–30% of the population by 2050 (1). Diabetes is, and will remain, a primary care medical issue, with >80% of patients with type 2 diabetes being managed by primary care providers (PCPs). Although diabetes is common, PCPs have found it to be one of the most challenging problems for which they provide care (2). In the past decade, there have been 18 new medications approved for glycemic control in the United States and six new classes of antihyperglycemic medicines (3). Two of these classes of medicines, incretin mimetics and the sodium–glucose cotransporter 2 (SGLT2) inhibitors, work through mechanisms that not only were unknown to any clinician who graduated >10 years ago, but were actually not well appreciated even when our current third-year residents in training were in medical school. That is how fast knowledge of diabetes and glycemic control has evolved. Add to that another 100 medicines for diabetes in the pipeline (4), and you can see how PCPs might feel a bit overwhelmed. Primary care residents have also found that keeping up with changes in diabetes management has become more challenging. This is, in part, because of changes in how medical students obtain knowledge about new medications and about the difficulties of being able to use those medications with patients. Most medical students' education about drugs begins in the classroom during the first 2 years. During this time, more emphasis is placed on medications' mechanisms of action and less on when they are appropriate to use for a given patient. In the third and fourth years, students are often bystanders, as they watch PCPs prescribe a select group of diabetes medications, often influenced by the socioeconomic and insurance status of the patients they are seeing. In many residency settings, we take care of the poorest members of the community, and it is more common to see patients on metformin, insulin, and sulfonylureas than on dipepti-dyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, or SGLT2 inhibitors. In addition, many university hospitals no longer allow drug representatives to have access to students, residents, or faculty to discuss the latest medications. Although critics have described the way these marketing interactions might negatively influence prescribing habits, such interactions also had …